radio- and radiochemotherapy of head and ......tonsilla, tonsillar arch, palatum molle, uvula,...
TRANSCRIPT
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RADIO - AND RADIOCHEMOTHERAPY OF HEAD AND NECK TUMORS
Zoltán Takácsi-Nagy PhD
Department of Radiotherapy
National Institute of Oncology, Budapest 1.
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• 550 000 NEW PATIENTS/YEAR WITH HEAD AND NECK CANCER ALL OVER THE WORLD (3-7 %) – THE SIXTH MOST COMMON HUMAN CANCER
• ETIOLOGY: TOBACCO, ALCOHOL, • ETIOLOGY: TOBACCO, ALCOHOL, BETEL NUTS, POOR DENTAL HYGIENE, NUTRITIONAL DEFICIENCY, VIRAL (HPV), GENETIC
• 60 % ARE STAGE III-IV. AT THE TIME OF THE DIAGNOSIS
2.
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INCIDENCE OF ORAL CAVITY AND PHARYNGEAL TUMORS IN CENTRAL EUROPE (cases/100 000
inhabitants)
Years Male Female
3.
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TUMORS OF THE HE AD AND NECK REGION CAN CAUSE A HIGH VARIETYOF SYMPTOMS – BECAUSE OF THEIR LOCATION – WHICH ARE OFTEN NOT
SPECIFIC
OPERATION OF A NECK DISEASE (LYMPH NODE) WITHOUT DETAILED HEAD AND NECK EXAMINATION IS
FORBIDDEN
4.
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• ULCERATIVE OR EXOPHYTIC LESIONS
• PAIN
• HOARSENESS
SYMPTOMS
• HOARSENESS
• NASAL SOUND
• SWALLOING DIFFICULTIES
• SPEACH DIFFICULTIES
• BLEEDING
• MASS ON THE NECK5.
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6.
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LOCALIZATION OF HEAD AND NECK CANCERS
LIP, ORAL CAVITYPHARYNX (Epipharynx, Mesopharynx, Hypopharynx) ~ 40 %LARYNX ~ 40 %NASAL, PARANASAL SINUSESSALIVARY GLANDSEYE, ORBITTHYROID GLANDTHYROID GLAND
HISTOLOGY90% planocellular carcinoma10% others: lymphoepithelial-, adenocarcinoma, lymphoma,sarcoma, melanoma
OCCULT METASTASIS IS FREQUENT!
7.
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UICC TNM CANCER STAGING
8.
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9.
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10.
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• HISTORY
• PHYSICAL EXAMINATION
• INSPECTION WITH HEADLIGHT OR HEADMIRROR
• ENDOSCOPE
EXAMINATION
• ENDOSCOPE
• PALPITATION
• CT, MRI, PET-CT, PANOREX
• HISTOLOGY, ASPIRATION CYTOLOGY
• CHEST X-RAY• ETC. (HPV) 11.
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12.
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T3N0 BASE OF TONGUE TUMORTUMOR
13.
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14.
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15.
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POSITRON EMISSION TOMOGRAPHY (PET)
PALATE TUMOR WITH SUPRACLAVICULAR LYMPH NODES ON BOTH SIDES (N2c)
16.
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17.
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EXTERNAL RADIOTHERAPY
MEGAVOLTAGE EQUIPMENT:
LINEAR ACCELERATOR - 6-18 MV PHOTONS or ELECTRONS
LINAC
18.
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TREATMENT PLANNING
CT-based 3D treatment planning
• Conformal 3D radiotherapy• Irregular, individually shaped fields
using “multi-leaf collimator” 19.
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BRACHYTHERAPY (BT)
20.
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CARCINOMA OF THE BASE OF TONGUE -
BRACHYTHERAPY
19.21.
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22.
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23.
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24.
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IN THE TREATMENT OF HEAD AND NECK TUMORS LOCOREGIONAL
TREATMENT IS A BASIC TREATMENT IS A BASIC REQUIREMENT
25.
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Stage III-IV. base of tongue cancer.
Histological results of N0 neck after dissection. 26.
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27.
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28.
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MULTIMODAL TREATMENT OF HEAD AND NECK TUMORS
SURGERYRADIOTHERAPYCHEMOTHERAPY
29.
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ADVANTAGES OF RADIOTHERAPY IN THE TREATMENT OF HEAD AND NECK TUMORS
• AVOIDING OF RADICAL SURGICAL METHODS
• PRACTICALLY NO MORTALITY
• GOOD COSMETIC AND FUNCTIONAL RESULTS
• ELECTIVE TREATMENT OF THE LYMPH NODES
• IN CASE OF FAILURE OF RADIOTHERAPY THE EFFECTIVENESS OF „SALVAGE” SURGERY IS SATISFACTORY
• IN SOME CASES IT IS AN EXCLUSIVE TREATMENT
• THERE ARE NO SIGNIFICANT CONTRAINDICATIONS
30.
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AIM OF RADIATION THERAPY
CURATIVE (total dose 50-80 Gy)
PALLIATIVE (total dose 30-60 Gy)
Curative treatment
• DEFINITIVE (exclusive)• DEFINITIVE (exclusive)
RADIOTHERAPY RADIOCHEMOTHERAPY
• POSTOPERATIVE (total dose: 50-66 Gy)
(eradiacation of microscopical residualis tumor cell)31.
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BEFORE RADIOTHERAPY
DENTAL CARE
IS REQUIRED!
32.
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MULTIMODAL TREATMENT OF HEAD AND NECK TUMORS
T1-2 N0-1
• RADIOTHERAPY or SURGERY (except epipharyngeal cancer )
T3-4 N0-3 or T1-4 N2-3
• RADIO/CHEMO/THERAPY• RADIO/CHEMO/THERAPY
• SURGERY +/- POSTOPERATIVE IRRADIATION or POSTOPERATI VE RADIOCHEMOTHERAPY
• INDUCTION CHEMOTHERAPY + RADIOCHEMOTHERAPY OR SURGERY
• CETUXIMAB + RADIOTHERAPY
33.
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RADIO CHEMOTHERAPY (RCT) IN THE THERAPY OF LOCOREGIONAL ADVANCED PHARYNGEAL AND
LARYNGEAL TUMOR
CONCOMITANT RCT: STANDARD TERATMENT
100 mg/m2 Cisplatin (days: 1, 22 & 43)100 mg/m2 Cisplatin (days: 1, 22 & 43)
LOCAL TUMORCONTROLL: 18-26%OVERALL SURVIVAL: 6,5 %
Pignon J.P., et al. Radiother Oncol 92:4-14, 2009. Meta-Analysis of Chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17346 patients
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RADIOSENSITIVITY OF PHARYNGEAL TUMORS
NASOPHARYNXOROPHARYNX
tonsilla, tonsillar arch, palatum molle, uvula, lateral and
+
posterior paharyngeal wall, base of tongue
HYPOPHARYNXsinus pyriformis, posterior pharyngeal wall, postcricoidregion
Radiosensitivity
-
35.
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RT OF NASOPHARYNGEAL TUMOR
• 90%poorly differentiated nasopharyngeal cc. (lymphoepitelioma)
• Radiosensitive tumor!
• PRIMARY TREATMENT =
RADIO/CHEMO/THERAPY
66-72 Gy EBI
60 Gy EBI + 4 x 4 Gy BT
36.EBI: external beam irradiation; BT: brachytherapy
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RT OF NASOPHARYNGEAL TUMOR
Lateral fieldEpipharynx + upper neck
Anterior fieldLower neck
37.
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BT OF NASOPHARYNGEAL TUMOR
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RT OF OROPHARYNGEAL TUMOR
PRIMARY TERATMENT: RT* or CONCOMITANT
RCT**
T1-2 N0-1 uvula, tonsilla, base of tongue: SURGERY
T3-4, N2-3: RADICAL SURGERY + POSTOP.RTT3-4, N2-3: RADICAL SURGERY + POSTOP.RT
QUALITY OF LIFE!!! (After surgery)
* Radiotherapy
** Radiochemotherapy
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RT OF OROPHARYNGEAL TUMOR
POSTOPERATIVE RT: 50-60 GyPRIMARY RT: 66-72 Gy
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BT – BASE OF TONGUE
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3-DIMENSIONAL (CONFORMAL) RADIOTHERAPY OF THE OROPHARYNGEAL TUMOR
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3-DIMENSIONAL (CONFORMAL) RADIOTHERAPY OF THE OROPHARYNGEAL TUMOR
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44.
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3-DIMENSIONAL (CONFORMAL) RADIOTHERAPY OF THE OROPHARYNGEAL TUMOR
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RT OF HYPOPHARYNGEAL TUMOR
PRIMARY TREATMENT:
T1-2N0 SURGERY +/- POSTOP. RT or RT
N+ or T2-4 SURGERY +/- POSTOP. RT/RCT or
RCT or INDUCTION CHEMOTHERAPY
46.
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RT OF GLOTTIC TUMOR
GLOTTIC-SUPRAGLOTTIC TUMOR:• T1-2 N0: RT ALONE or
SURGERY (QUALITY OF LIFE!!!)• T1-2 N+, T3 N0/+, EARLY T4 :
CONCOMITANT RCT orTOTAL LARYNGECTOMY (QOL!!!)
• ADVANCED T4 • ADVANCED T4 (SOFT TISSUE - BESE TONGUE): TOTAL LARYNGECTOM Y + POSTOP. RT
SUBGLOTTIC TUMOR:• STANDARD TREATMENT:
TOTAL LARYNGECTOMY + POSTOP. RT
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TREATMENT ALGORYTHM OF EARLY STAGE VOCAL CORD CANCE R
T1-2N0 vocal cord carcinoma
high differentiated T1N0 others
transoral laeser or RT RT
local recurrence
previously no RT previously RT
RT operation
recovery local recurrence inapposite for PO unadapted for PO-re
controll PL TL
recovery local recurrence
controll TL
RT: radiotherapy, PO: partial operation, PL: partial laryngectomy, TL: total laryngectomy 48.
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CUTAN LYMPHOMA – RT
before RT after RT
49.
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SKIN CANCER - RT
before RT after RT50.
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5-YEAR RESULTS OF PHARYNGEAL AND LARYNGEAL TUMORS TREATED WITH RADIOTHERAPY ALONE
60
50
40
(%)
40
30
20
10
0
NASOPHARYNXMESOPHARYNX LARYNX
HYPOPHARYNX
51.
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SIDE EFFECTS OF RADIOTHERAPY
• MUCOSITIS/EPITHELITIS
• XEROSTOMY (IMRT)
• DECREASED Ig-A LEVEL (CARIES)• DECREASED Ig-A LEVEL (CARIES)
• DETERIORATION OF SENSE OF TASTE
• SOFT TISSUE/OSTEORADIONECROSIS
• INJURY OF THE SPINAL CORD
52.
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53.
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54.
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55.